Modern Management of Urological Emergencies JOHN TUCKEY AUCKLAND CITY HOSPITAL Urologic Emergencies • discuss some of the commonest emergencies

• tips for diagnosis and management

• what you can do at your surgery

• when to refer Paraphimosis • is retracted and trapped behind the coronal sulcus

• venous and lymphatic obstruction results in oedema of glans and foreskin

• oedema can occlude arterial inflow to the foreskin and glans

• symptoms - mainly pain, communication issues may just be irritable

- extreme cases can have ischaemia Paraphimosis • who is at risk? - those with a , • when does it occur? - after sexual activity - patients we examine – always advance the foreskin post exam - elderly - patients or caregivers who fail to advance foreskin

Look for it – it is not rare Paraphimosis – How to reduce it

• ring block, 10-20 mls 1% lignocaine, no adrenaline!

• wait 5 mins Paraphimosis • compress the glans with thumb and forefinger

• push it through the narrow ring of the foreskin

• advance the foreskin

• success rates high

• refer to outpatients for Paraphimosis • if the foreskin will not advance or it is too painful, send to hospital

• likely to need reduction under anaesthesia or

• elective circumcision gives the best cosmetic result

• emphasise that they have nothing to eat or drink Priapsim • persistent erection that continues beyond or is unrelated to sexual stimulation and lasts over 4 hours

• two types - ischaemic high inflow but low outflow

- non-ischaemic high inflow and outflow

• ischaemic is the commonest by far Priapsim - Ischaemic • aetiology - intracavernosal injections, sickle cell, leukaemia

• increased intracavernosal pressure reduces arterial inflow

• causes hypoxia , acidosis and compartment syndrome

• if lasts 12 hrs, 50% have long term ED , if it lasts 24 hours 90% ED Priapsim - Ischaemic • present with a painful erection

• the erection looks normal

• beware older patients with no history of of using an erectogenic agent - direct infiltration from bladder or cancer Priapsim • investigation FBC if type of uncertain blood gases

• treatment local anaesthetic 19G butterfly + aspirate phenylephrine 10mg/ml, 1ml with 19 mls saline, use 1ml every 15-20 mins Priapsim

• most are treated in hospital

• if fails to settle a shunt is created

between corpora and glans What is this? • rupture of the tunica albuguinea

• usually occurs during intercourse

commonest position is missionary – erect penis hits pubic bone

• history and exam will give the diagnosis Penile Fracture • man hears a ‘pop’, has pain, swelling and detumescence

• urethral injury can occur - look for blood at the meatus

- ask if they have voided

• immediate surgical repair is the standard of care

• the patient is usually very embarrassed so encourage them to be seen Penile fracture

• possible complications include -

- Peyronie’s disease • pain without bruising is not a fracture - suspensory ligament

- pain + palpable lump Fournier’s

• a real urological emergency

• becoming more common

• patient presents with black areas on penis or scrotum

• may have bullae, crepitus or subcutaneous gas Fournier’s Gangrene • usually diabetics or older men

• can develop from insect bites, superficial abscesses

• usually have pain and a temperature

• rapidly progressive

• treatment is aggressive debridement and antibiotcs and grafting Macroscopic Haematuria

• initial stream haematuria usually urethra or prostate

• full stream haematuria anywhere

• terminal haematuria usually bladder base Haematuria • bleeding can be from anywhere

investigate both upper and lower urinary tracts

• useful numbers - microscopic 10% significant pathology

- macroscopic 30% significant pathology Haematuria • tumours may bleed only once every few months everyone with haematuria needs investigating

• painful haematuria usually an infection or a stone every male infection needs investigating females with an infection do not need investigating unless their infections are frequent or there are signs of pyelonephritis Haematuria • painless haematuria - often BPH in males - tumours - bladder - kidney - prostate Haematuria • investigation - FBC - urine culture - microscopic U/S and cystoscopy protein/creatinine ratio - macroscopic CT IVU and cystoscopy cytology or CX bladder Haematuria • admit those passing clots or in retention

• if managing at home advise - a high fluid intake if possible

- no exercise until it clears

• most bleeding settles

• refer to outpatients for investigations Haematuria • if you need to catheterise use a 22F 3 way or the biggest one you can find • small catheters do not drain the clots i.e 14 F • use two syringes of lignocaine jelly • the catheter will usually pass easily • wash the bladder out with 500 mls saline, bleeding usually stops when the clots are removed • refer to hospital for irrigation or if you don’t have the equipment Acute Scrotal Pain • usually a brief history of significant pain

• may have happened before

• often have nausea and vomiting

• usually no history of fever

• only have 6 hours to salvage the testis Testicular torsion • examination - testis usually high and transverse but NOT ALWAYS - don’t rely on Prehn’s sign or cremasteric reflex - if testis is normal look for a hernia, referred pain

• investigation? no it is a clinical diagnosis it is preferable to operate on than miss a torsion

• treatment - bilateral fixation, permanent suture What is this? Epididymitis • history is helpful how long - often 12 hours + onset - usually gradual sexual contact - unprotected sex, urethral discharge urinary infection - background of BPH, prostate surgery, dysuria, retrograde spread along vas lifting - reflux epididymitis Epididymitis • Examination - often have a temperature

- may have a cellulitis

- early on only the is tender and enlarged, but later the testis is also involved

- familiarity with normal anatomy will make diagnosis much easier • Investigation - MSU, STI check if appropriate - ultrasound Epididymitis • Treatment - if temp > 38 or cellulitis hospitalise - usually need 10 days of antibiotics - cover Chlamydia if STI a possibility - resting vital to prevent abscess or readmission - it may take 6 weeks to return to normal size - refer to outpatients if UTI or LUTS What is this? Torsion of an Appendage Torsion of an Appendage • usually a child or teenager

• the torted appendage may be visible through the thin scrotal skin

• usually treated conservatively - the appendage will slough off - excise if persistent/severe pain Urinary Retention • around 1/3 of men in retention may not have a history of LUTS

• nocturnal incontinence in a man is almost always due to chronic retention

• 90% are men

• 10% are women Urinary Retention • men

- occasionally retention precipitated by alcohol and constipation - rarely cord compression Urinary Retention

• women - gynaecology surgery, pregnancy, pelvic masses, constipation Urinary Retention • examination - always do a DRE and look at anal tone/sensation

- prostate size - fingers 2 - 30 cc (average) 3 - 60 cc 4 - 100 cc • investigation - creatinine

- urine if infection suspected

- PSA if DRE suspicious - usually impractical before IDC Urinary Retention • catheterisation - what size to use?

suspect BPH – start with 16F, increase size if not pass

suspect stricture – 12F

suspect clot retention – 22F 3 way

• tips 2 syringes of gel

measure volume drained, if > 1000 mls TROC unlikely to succeed Urinary Retention • measure hourly urine, if > 250 mls/hr admit

post obstructive diuresis

- occurs with elevated creatinine

- renal concentrating ability is slow to return when obstruction relieved

- can void 10 litres in a day so need IV support Renal Colic - Presentation

• typically - colicky - patient cannot get comfortable - nauseous or vomit - unilateral • beware - older patient – think AAA Presentation

• Renal - loin or back pain

• Ureteric - loin to groin

• Distal - beware - may be just frequency, urgency - strangury Examination • temperature - medical emergency

• abdominal exam - often just tender, look for peritonism, AAA, Murphy’s, hernia, other pathology

• back movements - do they precipitate / aggravate the pain Investigation

• MSU - microhaematuria (10% have no RBC’s)

- infection

• Blood - creatinine

- calcium hyperparathyroidism

- urate uric acid stones or as a nidus for Ca stones Radiology • a number of options exist

• what is your local practice?

• Auckland - diagnosis at local DHB

- referral to Auckland if treatment needed CT Urogram (C-) • accuracy around 99%

• quick

• best modality for ureteric stones

• most information - size and position of stones - anatomy CT Urogram (C-) • type of stone - density of the stone (Hounsefield units) - uric acid < 500U - calcium >800 • associated pathology

• ultra low dose 1.2 mSv same as a CXR

• other MRI - stones not visible Ultrasound • accuracy around 80%

• ureteric stones can be missed

• hydronephrosis infers a PUJ/ureteric stone

• ureteric jet present?

• no radiation so preferred for pregnancy or follow-up of recurrent stone formers Diagnosis – Plain X ray Initial Management

• need to know - stone size and position

- any signs of infection?

- single kidney or raised Cr ?

- pregnant?

- response to analgesia ? Management • refer acutely if - signs of infection

- ongoing pain

- significant dehydration

- renal impairment/single kidney

- pregnant Infection is a Real Emergency • infection coupled with obstruction

• patients can get sick very quickly - need urgent drainage

• REFER anyone with a stone and a temperature

• image all patients with a pyelonephritis early Infection is a Real Emergency Tabitha Mullings

- urosepsis

- delayed treatment

- gangrene of extremities

- 5 months rehab

- $USD18 million Initial Management what do you use for analgesia? Initial Management

• Analgesia - NSAID Diclofenac 75 mg unless high Cr

- Tramadol 100 mg

- refer for Morphine if not settle

• Fluids - increasing fluids does not increase the chance of passing the stone

- refer if dehydration an issue Natural History of Ureteric Stones • ureteric stones - 80-90% ≤ 5mm pass

- only 50% proximal stones ≤ 5mm pass

- usually pass in 6 weeks

- reimage at 6 weeks

- refer for removal if not pass or ≥ 7 mm Renal Stones

• renal stones - if ≥ 7 mm refer to clinic - if smaller monitor yearly until growth rate known - if smaller consider removing if travelling often - if the stone is peripheral there may be another reason for the pain

• any stone - refer if recurrent, multiple stones or young for further investigation Most Expensive Stone ? Most Expensive Stone William Shatner

Auctioned for $USD25000 Summary • paraphimosis, epididymitis, retention, some haematuria and small stones may be managed at your surgery

• infected stones, Fournier’s and torsions are medical emergencies

• ultrasounds are contraindicated if you are considering a torsion

• look out for a paraphimosis, they are usually reducible with a penile block

• penile fracture will need surgery and may need encouraging to be referred Summary

• epididymitis requires bed rest for a few days to avoid aggravating the infection • all haematuria and male infections need investigating

• beware of nocturnal incontinence in males, often chronic retention

• older patient with flank pain – think AAA

• ultra low dose CT scan have the same radiation as a CXR